I have recently become a guest commentator on New England Public Radio. Below is this month's essay. For those of you who would prefer to listen to me read this, click here.

Most mornings, there’s an elderly man in front of my office holding a sign that says: Thou shall not murder. I always hope my patients manage to avoid him. Better I carry his rage than they. It’s hard enough for them already.

As a midwife, I have been educated to protect the unborn from harm. But protecting from harm can also include showing mercy. I acknowledge that abortion, in the words of pro-life advocates, “stops a beating heart.” I especially struggle with the rightness of terminating a pregnancy when viewing second trimester ultrasounds of fetuses with clearly discernable bones and movement. But my sadness towards the fetus pales in comparison to any sadness I feel for a woman I care for who has decided to end her pregnancy. From my vantage point, having an abortion is, almost always, the lesser of two evils and often the only option that will allow her to continue to care for herself and the children she already has.

Opponents of abortion often suggest adoption as a reasonable alternative. But, after having so often witnessed the fierce attachment that forms immediately after birth between mother and newborn, I don’t see adoption as a sweeping alternative. Sure, there are plenty of people who are waiting to adopt an infant. But, the majority of children up for adoption are toddlers and primary school age kids who’ve been in foster care for years. Newspapers place their darling photographs and adorable bios. In their local sections all over the country, hoping someone will bite. What these bios. don’t include are these children’s trauma histories, which national data banks on US adoptions identify as being nearly universal among children in foster care. After years in temporary placement these children, like rescue dogs, just want a loving and permanent home. Perhaps abortion could have prevented their sad circumstances from ever occurring in the first place.

As a midwife, I protect both mothers and babies. When it comes having sanctity for life, my sense of this lands on the side of the pregnant women who come seeking my services. Their lives and the lives of the children they have chosen to have need protecting more than the embryos and fetuses they carry.

In this time of daily revelations about the exploitation of girls and women’s bodies as commodities, currency, and play-things, providing abortion services is one way I can lift up my voice, on a regular basis, and say: Women’s lives, their bodies, their children, and their choices really do matter.

Most women do not spend time thinking about their vaginas unless one of two things is happening: They’re crazy in love and thinking about sex all the time or there is something wrong down there. When women have itching, a bad odor, or pain it is hard to think about anything else other than ones vagina. The latter can come for plenty of legitimate reasons: yeast infections, a Herpes outbreak, or Bacterial Vaginosis and does warrant a trip to your GYN provider. However, what I encounter even more often than the Real McCoy of a problem are avoidable irritations created from washing one’s most delicate parts with Tide-strength perfumed body washes, wearing a bleached panty liner all the time, and the irritating side-effects of hair removal. These are sure-fire ways of creating uncomfortable and recurrent irritations that will cost you multiple co-payments and avoidable worries.

When I first started in practice – twenty years post-debut of Ms. Magazine - I didn’t see women for these hygiene-induced complaints. Now, I see them daily. Back then I think a kind-of Hippie mentality was more prevalent and women seemed to embrace their genitals with a more politically conscious, feminist appreciation. Today’s vulvas are not only subject to extraordinary cleaning and perfuming but their also rendered bald. For the past 15 years seeing a vulva with pubic hair has been a rarity. In the ‘90’s the only woman I knew who removed her pubic hair was a resident from Turkey who came to train with us. At the time, my partners and I found this an exotic practice from her middle-eastern home land. We weren’t seeing this replicated in any of our American patients, regardless of age. We all took it in stride and placed it under the general heading of cultural diversity. Nowadays, it’s usually only the over 50’s crowd that has any pubic hair whatsoever and when residents and students see this they almost always comment. Tables have turned and now the presence of pubic hair is the new exotica.

I asked an age-matched colleague of mine what he was told pubic hair was for when he was in medical school and his OB/GYN residency. He couldn’t recall if anyone had specifically mentioned its purpose but was able to tell me that the common understanding was that pubic hair was there to provide protection for the delicate vulvar and external genital tissues. Aha!! This is exactly my point! I voiced my conviction about this to my colleague who scoffed and told me it was ridiculous. He said the exemplary precedent we have for hair removal not damaging the skin is men’s daily facial shaving. But the skin on men’s faces is not the same as that of women’s vulvas. I couldn’t let this rest. So, I consulted with Dr. Google and don’t you know I was correct after all!

According to a number of articles the damage caused to hair follicles from waxing and other types of hair removal techniques is significant. Should a woman decide to resume a more au natural appearance, re-growth attempts may be unsuccessful and result in patchy, interspersed bald spots. So now, women are having pubic hair transplants – no kidding! This has become so prevalent that even Lady Gaga, Gwyneth Paltrow, and Cameron Diaz have come out with statements encouraging women to accept their naturally occurring pubic hair. Hair removal techniques are not only damaging to follicles but they make women look like pre-pubescent little girls. Other than our Turkish resident, the only women I knew of that shaved their pubic hair were porn stars in their efforts to make their genitals more visible. What is this saying about today’s American teens and women who want to be taken more seriously than ever before?

When it comes to best washing practices the only thing you really need is water. Separate the labial folds so you can rinse yourself off thoroughly. When I say this to patients, they think I am crazy. But, your genitals are not an EPA dump site. The only vaginas that are “dirty” are the ones that have an over-growth of bacteria, yeast, or a confirmed STI – it’s just that simple. As far as hair removal is concerned, I challenge every one of you who does this to ask yourself why. For the abundantly hairy person, clipping seems perfectly reasonable. But the bald vulva is not the normal vulva of an adult woman. There really is no reason to remove the pubic hair, unless you’re planning on selling it to women who have lost it from doing the same thing you’re doing and now want it back.

I never really gave Lady Gaga too much thought. Now, knowing she is encouraging women to leave their pubic hair as nature intended makes me want to buy every one of her recordings.

When women talk about a man’s bad behavior they’ll often say he’s thinking with his Dick. This is precisely how I feel about our new president’s intention to “dismantle Planned Parenthood.” In response, I am suggesting to all my patients and friends that it is time for women to start thinking with their Lady Parts, or shall I say, to quote our president, our Pussies. Gals, it’s time for our Pussie’s to work on our behalf and what better issue could there be for them to champion than access to contraception and sexual health care?

The idea of eliminating Title 10 funding feels disturbingly sinister, at the very least. Approximately 75% of patients who rely on Planned Parenthood for care are low-income people. And while a few of Planned Parenthood sites do provide abortion services, many do not. In fact, Planned Parenthood reports that 97% of the care they provide is not specific to abortion. Actually, they offer life-saving services like PAP smears, HIV prevention and screening, contraception, and basic GYN care. Our president and vice president’s Throwing-the-Baby-out-With-Bath-Water approach based on their “Pro-Life” stance has raised my index of suspicion of one or all of the following motives: a war on low-income Americans, a poorly informed effort to reduce the abortion rate below its current lowest rate ever, a desire for involvement in people’s sex lives (Yuck, what a thought!) or all of the above. Should Planned Parenthood funding end then millions of low income people will not have access to reproductive and sexual health care at all. The outcome will be catastrophic and the impact of that catastrophe will largely be shouldered by poor women and their kids.

At present it is estimated that over 45% of all pregnancies in the US are unintended. These are the result of either a method failure or because of not having contraception in the first place. In either case, pregnancy can be both expensive and risky to a woman. This is especially true for low-income women who are more likely to be in poor health when starting a pregnancy than wealthier ones. My experience has shown me that poor women often end up bearing the burden of pregnancy complications and then caring for their kids with little physical or financial support from anyone. With few social programs being funded and low-income men having little money themselves, poor women are often left on their own to make ends meet. In order to stop this from recurring, access to affordable and effective contraception is paramount. And men, RARELY IF EVER assume responsibility for this. This includes choosing to have a vasectomy when they themselves don’t even want more children. Men across class lines are so squeamish and protective of their penises that they refuse sterilization repeatedly. Despite the fact that most father’s today have witnessed their partner’s vagina performing extraordinary feats of accommodation in childbirth and are at least momentarily awestruck by the capacity and the pain it must cause, they still find the idea of a small snip and ice pack on their Dick’s just too risky or potentially uncomfortable to take on; more Dick thinking getting in the way of common sense, if you ask me. This leads to further reproductive burden landing on women’s shoulders.

I cannot count the number of times that a weary, exhausted, doing-her-best woman presents for a post-partum exam at 6 weeks after delivery and is pregnant. Why? In the words of one such patient: I just couldn’t argue with him anymore. He just wouldn’t give up! I had sex with him to get him off my back. Many of you reading this will immediately jump to the conclusion that this woman should show her he-man bully the door and never open it for him again. Trust me though, this happens to women who aren’t poor but they’re much more likely to have adequate contraception on board when it does. When my higher class patients present for a post-partum exam and sheepishly admit to having succumbed to their partners’ hassling them, despite my advice to the contrary, their far less likely to be pregnant. The reality in medicine is that women with more money are on the receiving end of more and better care which translates into more effective contraception. Health care providers, by and large, prefer caring for wealthier white women and earn more money doing so. Compare the salaries of clinicians who work for Planned Parenthood to those who work in a private or hospital-based practice and you’ll see what I mean. Folks that are on the front lines in a Title 10 clinic are activists who understand and deeply sympathize with what can and does happen to the poor if they don’t have access to care. Should the president succeed in “Dismantling Planned Parenthood” he will create greater disadvantages to the very constituents he appealed to during his campaign. This is just too weird!

I encourage you to let your Lady Parts help you think about what a poor woman faces when it comes to childbearing and parenting. Think about how burdensome it must be to face an unintended pregnancy simply because you couldn’t access effective contraception or your personal values don’t allow for a termination of pregnancy. Then, imagine what could happen to you should you be in the position of having lost your job and health insurance at the same time that your prescription for the pill is about to run out. My guess is if you do, you’ll better understand the importance of not dismantling Planned Parenthood, at least not before you get to the one closest to you.

I recently attended a conference on sexuality and gender with presenters whose scholarship, professional practice, and presentation styles were so rich and meaningful that I walked away with a mind full of new and enriched content. But, the binary thinking that we all fall prey to when it comes to sex and gender was a conference focal point that I can’t stop thinking about. This is in part because I tussle with this every day in my midwifery practice and am struggling to find ways to push against its force and hazards.

Customarily, an ultrasound is scheduled at almost 5 months of pregnancy to view and asses the fetus’ most life-supporting structures: brain, heart, lungs, stomach, kidneys, spine, and placenta - the stuff that makes us well when it’s working and unwell when it isn’t. When I mention this, most patients say something like: Oh, that’s the ultrasound you do so you can tell the sex of the baby, right? Wrong. It is the ultra sound we do to see if the baby’s anatomy looks normal or if there is a big problem we should be alerted to in advance. Despite my explanations and emphasis on this and my telling them that ultrasounds can be incorrect and/orthat the fetus may not be in a position that makes determining its sex possible, parents will persist; they ask when the scan will be repeated if the sex can’t be determined. Before their baby is able to sustain itself outside the womb expectant mothers and families have already determined aspects of selfhood based solely on their child’s genitals.

I had my own attachments to what my baby would be during pregnancy and for this reason I asked not to know its sex beforehand or at delivery. For about 15 minutes after birth, my newborn was completely sex and gender free. I wanted my mother’s love to solidify in that moment based solely on the baby being human, healthy, and mine. I sensed this was critically important but I couldn’t fully explain why.

What the conference speakers clarified for me so many years later is just how mutable identity can be at any time in life. Boy or girl, Straight or Gay, able or disabled, strong or frail, beautiful or homely. None of these are necessarily fixed nor should they be defined by anyone other than the individual themselves.

As a midwife, I am doing my best to remind people of what’s most important: human, healthy, safe in loving arms – the welcoming of a new member of the family. I can feel the burn of this uphill climb, but I know it’s entirely worth it.

A few years ago the cover story on my Mount Holyoke alumna news magazine was about Gabi Gregg, alumna, designer, and activist who had taken on fat-hating culture with a vengeance. Gabi is the brainchild behind the Fatkini, a two-piece bathing suit close enough in style and cut to be the bikini of choice for the full-figured woman. As a plus-sized gal myself I was totally intrigued by this. So, I went to the Gabifresh website to investigate. WOW! The models, their Fatkinis, and their bawdy poses – I was sold! The photos of Gabi herself modeling her swimwear poolside and being served by handsome and buff guys looking like they were trying to find their way into her Fatkini were my favorites. I told my spouse all about this and showed her which Fatkini I loved most. She was acknowledging and curious but then asked: And to what end do you love the Chartreuse Fatkini? When I told her I was going to buy it she said with a loving, but no-nonsense voice: That will not be happening. You will not be wearing a Fatkini this summer or any summer - unless you just wear it in the house. I was stunned and crestfallen. What started as a body affirming experience had been completely extinguished by the very person who tells me she loves my body in all its sizeable grandeur.

Robin’s response to my disappointment prompted a thought provoking question: Do you think Gabi might be missing a great opportunity about what swimwear should encourage, i.e. swimming? It was clear by the cut that one lap or dive into the water would loosen the top, turn my large breasts into flotation devices, and leave a graphic and lasting memory on the minds of my neighbors at our town beach. The Fatkini is not for swimming. Like every other bikini it is for showing off a woman’s body.

The Fatkini still captivates me BUT, I now believe Gabi would have been more successful addressing the politics of fat-hating – or fat fetishism – had she created beautiful, plus-size swimwear with athleticism in mind - handsome pool boys included. Feminists continue to toil in their efforts to enlighten us all about the cruelty and dangers of objectifying women’s bodies. My wearing a Chartreuse Fatkni would be like using a green highlighter pen from head to foot accentuating every curve and roll I have. Given that I love to swim and am motivated to do so why spend my hard earned cash on swimwear that would make swimming impossible and reinforce the myth that fat women are never athletic?

Clients 50 and older who come to me for sexuality counselingwith a chief complaint of decreased libido have often concluded before they arrive that their disinterest in sex is likely due to sexual ennui. This is especially the case if they’ve been in a long-term relationship. The assumption that the longer couples are together the more likely their sex life will be to lose its spark and appeal is a common misconception. In my way of thinking, when a person leads with: I have no interest in sex with my partnerthe first things I want to know are: Have you ever really enjoyed sex with him/her and, how have you changed as individuals and as a couple in the time you’ve been together?

A report of boring sex in the present is unlikely related to the longevity of the couple if great sex had been a part of their past. When I hear that someone is bored by their long-time mate it alerts me to look for signs and symptoms of stagnation in less obvious places, like the individuals themselves and/or the quality of their lives. Couples who have had good sexual chemistry from the get-go and maintain it over years are often individuals who embrace life’s challenges with more curiosity and resilience than fear and rigidity. When faced with disappointments and limitations they look for the lessons to be learned and are able to adapt by developing new and creative coping mechanisms. This is especially important as people age together. Those who still enjoy their sexual relationship tend to manage well with the duality of that was then and this is now.They don’t fall prey to melancholic revisiting of the past at the expense of experiencing joy in the present. And, when couples are sexually satisfied, occurrence rates are less likely to become an insurmountable sticking point.

The New Year is a great time for reflection. If there is no siren song emanating from your boudoir, read this eblast over a few times and ask yourself these questions: What else am I feeling bored with and how have we both managed with life’s challenges?

If you need help finding the answers remember, I do house calls, work by phone and on SKYPE.

I often counsel people who begin their sessions with the following statement: “I have never told anyone about this before.” Then, sheepishly and with reticence they disclose an erotic fantasy, finishing with a wince indicative of anticipatory terror over my response. The guilt and embarrassment that surrounds these disclosures relates to their desperate longing to understand “Where does this come from and why do I have it?” People worry terribly about what their fantasies might reveal about them and their real-life longings. This becomes clearer as the fantasy is spoken out loud and their anxiety mounts. I watch them bracing themselves for a response from me that confirms their greatest fear; they’re fantasy makes them a sexual pervert and will land them in a world of trouble.

My take on sexual fantasies is pretty straight-forward and uncomplicated; more power to you if you have them and they enhance your satisfaction. Fantasies are not the same as actions, which I find myself reminding people of all the time. This is where the glitch is. People feel and fear that having the fantasy in the first place somehow commits them to eventual, real-time activity even in the absence of any drive or desire for true-to-life experience. This is a bit like worrying that you’re at high-risk for committing a homicide when, after someone really pisses you off, you say: “I am going to kill him!”

When someone’s erotic fantasy is markedly in conflict with their outward identity or self-perception their distress over it becomes proportional to the mismatch between the two. For example, the ardent feminist who attends “Take Back the Night” rallies and tells me she fantasizes about a burly longshoreman “kind-of raping me” can’t easily admit this without feeling like something is very wrong or that she’s not a real feminist. Or, how about the man whose hottest fantasies are about sex with another man and a women but has no real, in-the-flesh desire for a same-sex partner? One fantasy that haunts both man and women often is when they imagine themselves having sex with another person while having great sex with their partner - who they actually want to be with. This can cause immeasurable distress until I speak the ultimate word of absolution: N-O-R-M-A-L!

I am convinced the reason so many of us struggle with our erotic imaginings is because we don’t have honest, detailed conversations with anyone about sex so we have absolutely no idea of what’s going on in other’s people’s minds. With nothing to compare our own fantasies to, it’s no surprise we scare ourselves half to death. Sadly, by the time many people end up in my office they’ve succeeded in torturing themselves with worry over fantasies they happen to share with large portions of the population and which reflect nothing more than an amalgam of historical influences mixed with great imagination. For anyone reading this who can relate to what I am writing, I encourage you –first and foremost – to stay calm! Chances are good that whatever your fantasy is, it’s more normal than you think. And don’t spend too much time trying to figure out where your fantasies come from and why. As long as you’re not coercing someone in real-life or committing a crime, enjoy yourself and stop throwing your sexual satisfaction under-the-bus. Remember, it’s a fantasy, not a contract for real life action.

2. Good Sex is Worth Waiting For

The number one complaint of women that I see for sexuality counseling is that they have no libido – zip, gone, disappeared. They tell me they’d rather do just about anything else than have sex; bake 100 cupcakes at midnight, shovel snow, or do laundry. Contrary to what many of us assume, this happens to women of all ages and levels of love, attachment, and attraction to their partners. This is not just a problem for the post-menopausal set who feels as though their mojo went out the window and their hot flashes took its place. But, this is not always an actual absence of libido. A woman’s lack of being turned-on physically is not necessarily reflective of a lack of desire for sex but a misunderstanding of how she gets turned on in the first place. With no owner’s manual to refer to and in the face of rampant sexual illiteracy, how could any woman be expected to know how their actual turn-on mechanism works?

A woman’s brain has a smaller area than a man’s’ that controls sex drive and action. This are has also been predominantly shaped by estrogen, not testosterone. These two differences demand we finesse and lure our physical sensations of desire out of hiding every time we look for them.

Women often initiate sex from a longing for intimacy versus blatant, undeniable sensations of physical desire. Men, on the other hand, are slaves to the beat of the figurative sexual Tom-Tom and have the neuro-anatomy and chemistry to let their erections steer the ship. Few women are aware – never mind sympathetic - to this and falsely label men’s sex drive as a primitive, uncontrolled, and offensive objectification of them – oh contraire! In my opinion, men are the lucky ones. Meanwhile, women are searching for a propulsive force only to give up the ship entirely when they can’t find one within moments of initiating some kind-of sex play. In the absence of a physical sensation of arousal beyond a minute or so, women throw in the towel and head towards the laundry, lunches, or emails instead of hanging in-there and coaxing their arousal to surface. Yet again, we mistake our lack of sensation for an overall lack of interest.

Many women need 5-20 minutes of warm-up time before they start to feel the unmistakable sensation of being tuned-on. And it is possible that these sensations may never occur. Having been in this position myself, I have stayed in the moment just to see what happens. It’s not so bad. Having sex when your head says: “give it a go” but your body says: ”what, are you kidding, now?” is kind-of like exercising when you’d rather be watching television. Most people who are conscience about their health go out and hike and end up being glad they did, even if the hike they took wasn’t their best. I have decided sex isn’t so different. So what if your sexual experience was a C-? There are no sex police who will arrest you nor will you be fired from your relationship. Welcome to the Likert scale of human sexual experience. On a scale of 1-5, you either strongly agree that your sex was great or strongly disagree. You win some, you lose some. The stakes don’t need to be so high and the only people who have control over this are the people who have sex with one another.

Take the pressure off yourself and your partner. Sexual experiences fall on a continuum –some are hotter than others. It’s really that simple.

3. Sex and Death Have Something in Common

Having an appreciation for gallows humor coupled with the recent experience of helping two family members die in hospice care, I naturally stumbled upon a relationship between talking about death and talking about sex. Grave and sullen voices whisper feelings and facts - both good and bad - in hushed and secretive tones when discussing either topic. People speak as though they’re disclosing something unlawful or horrific when they say something about either subject. Statements like: “I think she’ll die soon, given how bad her color is” or “I really love the new sex toys I just bought!” become akin to something unlawful or horrific like: “I’m counter-fitting twenties in my basement” or “I know it’s hard to believe but I love dealing crystal meth. at the elementary school.” How is it that two of the most natural events in people’s lives are two we find most difficult to discuss?

Discussions about death and dying are rough terrain, to be sure. The obvious sorrows are complex and weighty. But last I knew, sex was one of the nicer things in life so why the tones of covert operations? Folks who come to see me to discuss sexual longings, problems, or the desire to make good sex better tend to drop their voices at least one octave when they recite the specifics. I feel as if they’re worried about being marked like Hester Prynne should they reveal the truth. Why the hesitancy to have earnest conversations in a normal tone of voice?

In order to talk about anything with confidence and fluency you need a basic vocabulary and plenty of practice. I suspect that the language of sex is not unlike any other foreign language acquisition process: people speak in hush, grim tones because they are under-confident and have no sense of certainty that they’ll say things the “right “way. And, they’ve never been given the opportunity to practice. Let’s face it, how many families consider human sexuality an appropriate topic for dinner table conversation? Maybe if the kids bring up sex ed. in school, the parents might deign to discuss human reproductive biology. But that has nothing to do with lust, arousal, orgasm, or desire. This is where and when the seeds of muteness are sown, or not. Of course most parents have no fluency themselves so it’s hard for them to be helpful.

I say, practice in your mirror. Come up with your most difficult vocabulary list of sex words and phrases – masturbation, anal sex, oral sex, nipples, BDSM – and practice saying them in your mirror in a normal tone of voice. No whispering allowed. Lastly, try adding a lilt. When you tell yourself: “I L-O-V-E having my hands tied above my head!” say it with happiness, not as though you’re headed to the guillotine, unless, of course this is part of your fantasy, too. This will surely increase your chances of getting more of what you want out of your experiences because you’ll be more likely to ask for it.

As for dying, I urge you not to be fearful or reticent about this either. None of us leave here alive and we only die once. Take the necessary measures to ensure you will have no regrets when you say farewell to the one(s) you love.